Eyeworld

EW RETINA 68 December 2016 by Rich Daly EyeWorld Contributing Writer Approaches to intravitreal anti-VEGF injections differ Surgeons outline keys to their approach to the treatment, which has a role in a growing number of conditions I ncreasing use of anti-VEGF agents in ocular conditions has led to differing roles among retina specialists. Lloyd Clark, MD, assistant clinical professor of ophthalmology, University of South Carolina School of Medicine, Columbia, South Caro- lina, uses Eylea (aflibercept, Regen- eron Pharmaceuticals, Tarrytown, New York), Lucentis (ranibizumab, Genentech, South San Francisco), and Avastin (bevacizumab, Genen- tech) for intravitreal injections. "That being said, I prefer uti- lizing [Food and Drug Administra- tion]-approved therapies as an initial drug choice," Dr. Clark said. Dr. Clark noted that some circumstances—such as payer and reimbursement issues—necessitate the choice of Avastin, "and the good news is that these patients often respond well to treatment." Dr. Clark prefers Lucentis and Eylea based less on efficacy than "the possible, but infrequent, risks of contamination or reduced activity of Avastin as it is compounded." "In terms of the choice between Eylea and Lucentis, they are both great options, and by and large I see them as equivalent for primary treat- ment of age-related macular degen- eration," Dr. Clark said. David Boyer, MD, clinical professor of ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, starts all patients on Avastin unless the patients do not want to use a non-FDA approved drug after the risks, benefits, and alternatives of the three drugs are explained. "I change drugs depending on the treatment response," Dr. Boyer said. Keys to technique Dr. Clark's injection technique typi- cally involves the use of a dedicated injection room and a highly skilled and experienced technician who prepares patients for the injection. Once a patient has been examined and Dr. Clark has decided an injec- tion is warranted, the technician prepares the patient's eye with a sterile betadine solution. Dr. Clark uses sterile gloves, inserts a sterile lid speculum, and then performs the intravitreal injection. "We think this technique, although somewhat time-consum- ing and costlier, is the safest for our patients," Dr. Clark said. For Dr. Boyer, the key to en- dophthalmitis prevention is the use of 5% povidone iodine. Dr. Clark has discontinued his use of perioperative antibiotics due to research that found no ability to decrease the incidence of infections. "We do perform a complete betadine prep, use sterile gloves and speculum, and proactively manage patients with blepharitis," Dr. Clark said. Optical coherence tomography (OCT) is an important diagnostic tool in the initial evaluation of patients receiving intravitreal injec- tions, Dr. Clark said. But OCT is also critical in the ongoing evaluation of treatment response to anti-VEGF agents. "It is critical to examine more than just topography or the central scan, but also to take the time to look at multiple images, particularly in areas of pathology from fluores- cein or indocyanine green angiogra- phy," Dr. Clark said. "For example, subretinal fluid is a worrisome D avid Boyer, MD, and Lloyd Clark, MD, have played key roles in many AMD, diabetic macular edema and vein occlusion clinical trials. Not only have they recruited large numbers of patients, they have been involved in clinical trial design, data safety monitoring committees, data analysis, and reporting the results at key society meetings and in the peer-re- viewed literature. They have vast clinical experience in treating these disorders and others treated with anti-VEGF therapy outside the clinical trial space; real world experience is crucial. Their comments provide significant in- sight into the management of patients with wet AMD, DME, and RVO. I strongly agree with their approach to sterile injection tech- nique, OCT monitoring, adjusting treatment intervals based on response, and using the more effective FDA-approved agents when feasible from a patient cost and reimburse- ment perspective. Close adherence to treatment intervals correlated with pharmacokinetic infor- mation and patient response is crucial. Understanding that DME and CRVO produce approximately 5,000 times more VEGF than wet AMD coupled with knowledge that Lucentis and Eylea have much greater affin- ity for VEGF than Avastin is crucial. Avastin produced somewhat worse outcomes than Lucentis in the Comparison of AMD Treatment Trials (CATT); this does not apply to DME. DRCR.net Protocol T showed that Eylea was more effective than Lucentis and Lucentis was more effective than Avastin when there was significant edema. Steven Charles, MD, Chair, ASCRS Retina Clinical Committee Retina consultation corner Dr. Charles performs an intravitreal injection at Charles Retina Institute. Source: Steve Charles, MD

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